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Study Objective: Half of emergency department (ED) patients aged 65 years and older are discharged with new prescriptions. Potentially inappropriate prescriptions contribute to adverse drug events. Our objective was to develop an evidence- and consensus-based list of high-risk prescriptions to avoid among older ED patients., Methods: We performed a modified, 3-round Delphi process that included 10 ED physician experts in geriatrics or quality measurement and 1 pharmacist. Consensus members reviewed all 35 medication categories from the 2019 American Geriatrics Society Beers Criteria and ranked each on a 5-point Likert scale (5=highest) for overall priority for avoidance (Round 1), risk of short-term adverse events and avoidability (Round 2), and reasonable medical indications for high-risk medication use (Round 3)., Results: For each round, questionnaire response rates were 91%, 82%, and 64%, respectively. After Round 1, benzodiazepines (mean, 4.60 [SD, 0.70]), skeletal muscle relaxants (4.60 [0.70]), barbiturates (4.30 [1.06]), first-generation antipsychotics (4.20 [0.63]) and first-generation antihistamines (3.70 [1.49]) were prioritized for avoidance. In Rounds 2 and 3, hypnotic "Z" drugs (4.29 [1.11]), metoclopramide (3.89 [0.93]), and sulfonylureas (4.14 [1.07]) were prioritized for avoidability, despite lower concern for short-term adverse events. All 8 medication classes were included in the final list. Reasonable indications for prescribing high-risk medications included seizure disorders, benzodiazepine/ethanol withdrawal, end of life, severe generalized anxiety, allergic reactions, gastroparesis, and prescription refill., Conclusion: We present the first expert consensus-based list of high-risk prescriptions for older ED patients (GEMS-Rx) to improve safety among older ED patients., (Copyright © 2024 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Study Objective: To test the hypothesis that provider-to-provider tele-emergency department care is associated with more 28-day hospital-free days and improved Surviving Sepsis Campaign (SSC) guideline adherence in rural emergency departments (EDs)., Methods: Multicenter (n=23), propensity-matched, cohort study using medical records of patients with sepsis from rural hospitals in an established, on-demand, rural video tele-ED network in the upper Midwest between August 2016 and June 2019. The primary outcome was 28-day hospital-free days, with secondary outcomes of 28-day inhospital mortality and SSC guideline adherence., Results: A total of 1,191 patients were included in the analysis, with tele-ED used for 326 (27%). Tele-ED cases were more likely to be transferred to another hospital (88% versus 8%, difference 79%, 95% confidence interval [CI] 75% to 83%). After matching and regression adjustment, tele-ED cases did not have more 28-day hospital-free days (difference 0.07 days more for tele-ED, 95% CI -0.04 to 0.17) or 28-day inhospital mortality (adjusted odds ratio [aOR] 0.51, 95% CI 0.16 to 1.60). Adherence with both the SSC 3-hour bundle (aOR 0.59, 95% CI 0.28 to 1.22) and complete bundle (aOR 0.45, 95% CI 0.02 to 11.60) were similar. An a priori-defined subgroup of patients treated by advanced practice providers suggested that the mortality was lower in the cohort with tele-ED use (aOR 0.11, 95% CI 0.02 to 0.73) despite no significant difference in complete SSC bundle adherence (aOR 2.88, 95% CI 0.52 to 15.86)., Conclusion: Rural emergency department patients treated with provider-to-provider tele-ED care in a mature network appear to have similar clinical outcomes to those treated without., (Copyright © 2022 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Study Objective: The objectives of this study were to describe the reach and adoption of Geriatric Emergency Department Accreditation (GEDA) program and care processes instituted at accredited geriatric emergency departments (EDs)., Methods: We analyzed a cross-section of a cohort of US EDs that received GEDA from May 2018 to March 2021. We obtained data from the American College of Emergency Physicians and publicly available sources. Data included GEDA level, geographic location, urban/rural designation, and care processes instituted. Frequencies and proportions and median and interquartile ranges were used to summarize categorical and continuous data, respectively., Results: Over the study period, 225 US geriatric ED accreditations were issued and included in our analysis-14 Level 1, 21 Level 2, and 190 Level 3 geriatric EDs; 5 geriatric EDs reapplied and received higher-level accreditation after initial accreditation at a lower level. Only 9 geriatric EDs were in rural regions. There was significant heterogeneity in protocols enacted at geriatric EDs; minimizing urinary catheter use and fall prevention were the most common., Conclusion: There has been rapid growth in geriatric EDs, driven by Level 3 accreditation. Most geriatric EDs are in urban areas, indicating the potential need for expansion beyond these areas. Future research evaluating the impact of GEDA on health care utilization and patient-oriented outcomes is needed., (Copyright © 2021 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Study Objective: We validate the Clinical Frailty Scale by examining its independent predictive validity for 30-day mortality, ICU admission, and hospitalization and by determining its reliability. We also determine frailty prevalence in our emergency department (ED) as measured with the Clinical Frailty Scale., Methods: This was a prospective observational study including consecutive ED patients aged 65 years or older, from a single tertiary care center during a 9-week period. To examine predictive validity, association with mortality was investigated through a Cox proportional hazards regression; hospitalization and ICU transfer were investigated through multivariable logistic regression. We assessed reliability by calculating Cohen's weighted κ for agreement of experts who independently assigned Clinical Frailty Scale levels, compared with trained study assistants. Frailty was defined as a Clinical Frailty Scale score of 5 and higher., Results: A total of 2,393 patients were analyzed in this study, of whom 128 died. Higher frailty levels were associated with higher hazards for death independent of age, sex, and condition (medical versus surgical). The area under the curve for 30-day mortality prediction was 0.81 (95% confidence interval [CI] 0.77 to 0.85), for hospitalization 0.72 (95% CI 0.70 to 0.74), and for ICU admission 0.69 (95% CI 0.66 to 0.73). Interrater reliability between the reference standard and the study team was good (weighted Cohen's κ was 0.74; 95% CI 0.64 to 0.85). Frailty prevalence was 36.8% (n=880)., Conclusion: The Clinical Frailty Scale appears to be a valid and reliable instrument to identify frailty in the ED. It might provide ED clinicians with useful information for decisionmaking in regard to triage, disposition, and treatment., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

In 2018, the American College of Emergency Physicians (ACEP) began accrediting facilities as "geriatric emergency departments" (EDs) according to adherence to the multiorganizational guidelines published in 2014. The guidelines were developed to help every ED improve its care of older adults. The geriatric ED guideline recommendations span the care continuum from out-of-hospital care, ED staffing, protocols, infrastructure, and transitions to outpatient care. Hospitals interested in making their EDs more geriatric friendly thus face the challenge of adopting, adapting, and implementing extensive guideline recommendations in a cost-effective manner and within the capabilities of their facilities and staff. Because all innovation is at heart local and must function within the constraints of local resources, different hospital systems have developed implementation processes for the geriatric ED guidelines according to their differing institutional capabilities and resources. This article describes 4 geriatric ED models of care to provide practical examples and guidance for institutions considering developing geriatric EDs: a geriatric ED-specific unit, geriatrics practitioner models, geriatric champions, and geriatric-focused observation units. The advantages and limitations of each model are compared and examples of specific institutions and their operational metrics are provided., (Copyright © 2019 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Study Objective: Renal colic is common and computed tomography (CT) is frequently used when the diagnosis of kidney stone is suspected. CT is accurate but exposes patients to ionizing radiation and has not been shown to alter either interventional approaches or hospital admission rates. This multiorganizational transdisciplinary collaboration seeks evidence-based, multispecialty consensus on optimal imaging across different clinical scenarios in patients with suspected renal colic in the acute setting., Methods: In conjunction with the American College of Emergency Physicians (ACEP) Emergency Quality Network, we formed a 9-member panel with 3 physician representatives each from ACEP, the American College of Radiology, and the American Urology Association. A systematic literature review was used as the basis for a 3-step modified Delphi process to seek consensus on optimal imaging in 29 specific clinical scenarios., Results: From an initial search yielding 6,337 records, there were 232 relevant articles of acceptable evidence quality to guide the literature summary. At the completion of the Delphi process consensus, out of the 29 scenarios agreement was rated as perfect in 15 (52%), excellent in 8 (28%), good in 3 (10%), and moderate in 3 (10%). There were no scenarios in which at least moderate consensus was not reached. CT was recommended in 7 scenarios (24%), with ultrasonography in 9 (31%) and no further imaging needed in 12 (45%)., Conclusion: Evidence and multispecialty consensus support ultrasonography or no further imaging in specific clinical scenarios, with reduced-radiation-dose CT to be used when CT is needed for patients with suspected renal colic., (Copyright © 2019 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Due to a miscommunication during the process of transferring this manuscript from our editorial team to Production, the Members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) were not properly indexed in PubMed. This has now been corrected online. The publisher would like to apologize for any inconvenience caused., (Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Study Objective: We evaluate the diagnostic test characteristics of the Six-Item Screener and the AD8 to detect cognitive dysfunction in adults older than 65 years and using the emergency department (ED) for any reason., Methods: We conducted an observational cross-sectional cohort study at a single academic urban university-affiliated hospital. Subjects were consenting, non--critically ill, English-speaking adults older than 65 years and receiving care in the ED. We quantitatively assessed the diagnostic test characteristics of the Six-Item Screener and AD8 by using the Mini-Mental State Examination score less than 24 as the criterion standard for cognitive dysfunction., Results: The prevalence of cognitive dysfunction was 35%, but only 6% of charts noted a pre-existing deficit. The Six-Item Screener was superior to either the caregiver-administered AD8 or the patient-administered AD8 for the detection of cognitive dysfunction., Conclusion: The Six-Item Screener was superior to the caregiver- or patient-administered AD8 to identify older adults at increased risk for occult cognitive dysfunction., (Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)